Professional Documents
Culture Documents
HISTORIA CLINICA
FICHA DE IDENTIFICACION:
Nombre:____________________________________________________Edad:___________Sexo:________
Ocupación:________________Estado Civil:_____________Nacionalidad:____________________________
Residencia_____________________Escolaridad:________________________Religión:_________________
Servicio:________________________Cama:________ No. Expediente:______________________________
ANTECEDENTES HEREDOFAMILIARES:
Hermanos:....................Vivos:................................Fallecidos:..............................................................................
………………………… …… Causas:..................................................................................
Hijos:............................Vivos:..................................Fallecidos:............................................................................
Causas:……............................................................................
Tuberculosis SI ⃝ NO ⃝ __________________________________________________________
Cáncer SI ⃝ NO ⃝ __________________________________________________________
1) Hábitos Tóxicos:
Alcohol: __________________________Tabaco:_________________________Drogas:_________________
2) Fisiológicos:
Alimentación:____________________________________________________________________________
Dipsia:__________________________________________________________________________________
Diuresis: ________________________________________________________________________________
Catarsis:_________________________________________________________________________________
Somnia:_________________________________________________________________________________
Otros:__________________________________________________________________________________
Tuberculosis SI ⃝ NO ⃝ __________________________________________________________
Cáncer SI ⃝ NO ⃝ __________________________________________________________
Quirúrgicos:______________________________________________________________________________
Traumatológicos:_________________________________________________________________________
Alérgicos: _______________________________________________________________________________
Otros: __________________________________________________________________________________
GINECO-OBSTÉTRICOS:
Otros: __________________________________________________________________________________
PADECIMIENTO ACTUAL
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
INTERROGATORIO POR APARATOS Y SISTEMAS
Aparato respiratorio:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Aparato digestivo:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Aparato cardiovascular:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Aparato genital:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Sistema endocrino:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Musculo esquelético:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Sistema nervioso:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Síntomas generales:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EXPLORACIÓN FÍSICA:
Inspección general:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Cabeza:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Cuello:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Tórax:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Abdomen:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Tacto vaginal y rectal:
________________________________________________________________________________________
Extremidades:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Exploracion neurológica:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EXAMENES COMPLEMENTARIOS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
DIAGNOSTICO PRESUNTIVO:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PLAN TERAPÉUTICO:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________